Increasing the Value of Continuous Monitor Use in the Hospital
Critically ill children, and those receiving anesthesia in the operating room, benefit tremendously from continuous physiologic monitors that track blood oxygen levels, heart rate, and respiratory rate every five seconds. However, use of these monitors is spreading to hospital medicine units which commonly care for less ill children. In this context, there is no evidence showing continuous monitors improve outcomes, and observational data suggests these monitors may prolong hospital stays. This year, Amanda Schondelmeyer, MD, published two studies where she and her research team used mixed methods to better understand how nurses, respiratory therapists, and providers interact with monitors and monitor alarms. In qualitative research she found that clinicians perceived monitors may lead to anxiety and poor sleep for families, and interruptions and fatigue for clinicians. In a second study using direct observation, Dr. Schondelmeyer found in >200 hours of observation that nurses use their expertise and contextual clues to tailor their response to alarms; nurses intervened for only a small minority (7%) of all alarms.
Leveraging Dr. Schondelmeyer’s foundational findings of the consequences of monitor over-use, Dr. Schondelmeyer and Patrick Brady, MD, MSc, serve as co-investigators in a multicenter, NIH-funded study aiming to de-implement continuous pulse oximetry in low-risk children with bronchiolitis, a viral respiratory infection that is the leading cause of hospitalization for infants. In the recently completed first aim of this research, the team found a significant number of infants across the country are over-monitored. Over-monitoring is similar across large children’s hospitals and community hospitals. The 58-hospital study leverages the Pediatric Research in Inpatient Settings network. Samir Shah, MD, MSCE, is vice chair, while Dr. Brady serves on the executive council of this network. Katherine Auger, MD, MSC, and Joanna Thomson, MD, MPH, both serve as associate executive council members.
Improving Communication with Community Physicians
A previous modification implemented routine calls with community physicians to discuss patients at admission rather than at the time of patient discharge. The impetus for this change was to improve the yield of these calls by discussing pertinent patient history that would inform the plan of care. We recognize that opportunities to improve communication remain. Our internal tracking data revealed that although 90% of community physicians returned our calls, one-third of the time we spoke with someone other than a physician or APRN. Furthermore, fewer than 20% of returned calls resulted in meaningful transfer of information, and only 4% yielded any change in the care plan.
To improve communication while remaining mindful of time constraints in the office setting, Craig Gosdin, MD, MSHA, and Austin Ostermeier, MD, MS, partnered with multiple stakeholders, including the community physician sextant leadership group, the residency program, physician priority link leadership, and joint commission compliance. The group developed a process to efficiently identify circumstances that warrant direct communication between the hospital medicine team and the community physician with a goal of higher yield calls. The team also engaged community physicians to help define the value in various communication opportunities and incorporate LEAN methodology through a pilot test on one hospital medicine team before a division-wide roll out.
Creating a Diagnostic "Safety Net"
Recent estimates suggest that one in 10 Americans each year suffers from a diagnostic error, making improving diagnosis the next major imperative for patient safety. Recognizing and communicating when a patient’s diagnosis is “uncertain” can reduce errors, mitigate potentially unnecessary testing, and improve patient outcomes and physician well-being. Philip Hagedorn, MD, and Anna Ipsaro, MD, MBE, led the creation of a process to identify patients with uncertain diagnoses early in their hospitalization through thoughtful engineering of clinical workflows. Through a series of improvement science interventions, the communication of diagnostic uncertainty increased several-fold.
In related work, hospital medicine fellow, Trisha Marshall, MD, and colleagues developed a system to learn from physician reporting of diagnostic learning opportunities, or events when there was an opportunity to make a more accurate or timely diagnosis. Before this improvement science work, only one reported potential diagnostic error occurred in the prior four years, leaving little opportunity for providers, researchers, and improvers to learn about this important source of harm. To date, Dr. Marshall and team identified >100 physician-reported diagnostic learning opportunities. The team analyzed each event using two validated diagnostic error analysis tools, discovering these potential errors were usually multifactorial and most commonly occurred in the assessment phase.
The Future of Pediatric Hospital Medicine
The Cincinnati Children's Division of Hospital Medicine is leading the way in developing hospital medicine as the newest pediatric subspecialty certified by the American Board of Pediatrics. Dr. O’Toole serves as a member of the ABP Hospital Medicine sub-board. Additionally, the inaugural Cincinnati Children's PHM Boards Preparation course, held in September 2019 to prepare hospitalists for the initial certification exam, sold out with attendance by hospitalists from more than 20 States. Course Directors, Yemisi Jones, MD, and Lisa Herrmann, MD, MEd, included Benjamin Kinnear, MD, MEd; Laura Piper, MD; Shivani Patel, DO, MS; and Amy Rule, MD, MPH, on their planning team .Other Significant Accomplishments
Excellence of Division Fellows and Faculty Fellows
As the field transitions to sub-specialty status under the American Board of Pediatrics, the fellowship in Pediatric Hospital Medicine continues to grow.
Cincinnati Children's fellowship program takes a prominent role in national leadership coordinating the growth and development of Pediatric Hospital Medicine (PHM) fellowships nationally. Karen Jerardi, MD, MEd, program director, served as vice-chair of the Council of Pediatric Hospital Medicine Fellowship Directors from 2017-2019 and will assume the position of chair this year. In this role she will lead this council, which includes programs from >50 hospitals, as they continue work to ensure quality PHM fellowships nationally and serve as a resource for new PHM fellowships in development. Dr. Thomson, associate program director and elected vice-chair of the Research Committee of the Council, will focus on improvements for research training within fellowship programs. Additionally, Cincinnati Children's PHM Fellowship hosted a conference funded through the Agency for Healthcare Research and Quality (AHRQ) R13 (PI: Dr. S. Shah) in conjunction with the Council of PHM Fellowship Directors and the Pediatric Research in Inpatient Settings (PRIS) Network in the Spring of 2019. At this two-day conference fellowship program directors from across the country and leaders in PHM research gathered to develop a framework for a national research curriculum and create resources to share across fellowships to ensure all PHM fellowship graduates receive high quality research training.
The success of our fellows over the past year included significant contributions to the care of hospitalized children.
Ashley Jenkins, MD, received both the Academic Pediatric Association Young Investigator and Society of General Internal Medicine Founders Awards to further her work studying the timing of and factors mediating the transition from pediatric to adult care for adolescents and young adults with chronic conditions originating in childhood. She presented preliminary findings from this work in a platform presentation at the Academic Pediatric Association 2019 meeting of the Pediatric Academic Societies.
Dr. Marshall recently received acceptance into the American Board of Medical Specialties Visiting Scholar Program. In conjunction with the Gordon and Betty Moore Foundation, this program funds her research in how to improve the recognition of diagnostic uncertainty and understand its impact on patient and system level outcomes. The goal of this research is to identify diagnostic coding and language patterns—or uncertainty signatures—that clinicians employ when facing an unclear diagnosis. If successful, the developed identification tools have the potential use to proactively identify and mitigate situations where uncertain diagnoses could lead to overuse or harm through diagnostic error.
Sonya Tang Girdwood, MD, PhD, is leading a research program evaluating the pharmacokinetic variability and pharmacodynamic attainment of beta-lactam antibiotics in critically ill children with the plan to implement model-informed precision dosing. She received a 2019 Arnold W. Strauss Clinical Fellow Award to study ceftriaxone and piperacillin/tazobactam in different phases of sepsis. The National Institute of Child Health and Human Development T32 Clinical Pharmacology Program selected Dr. Tang Girdwood to serve as national chief fellow based on her advocacy in supporting research that integrates clinical pharmacology into general pediatrics, research accomplishments, clinical experience, and organizational skills.
Faculty:
Dr. Brady became a named fellow of hospital medicine through the Society of Hospital Medicine.
Dr. Hagedorn received an appointment as associate chief medical information officer for Cincinnati Children's. Dr. Hagedorn completed his masters of biomedical informatics at Oregon Health & Science University while working under Cincinnati Children's chief medical information officer Andrew Spooner, MD, MS, FAAP, as a clinical informatics subject matter expert. His new role will focus on creating a clinical informatics community capable of creating tomorrow’s leaders in the field and moving our institution to a new, higher level of informatics sophistication where knowledgeable users equipped with actionable data to make pediatric care safer, more efficient and more effective.
Dr. Jerardi, received the prestigious national Pediatric Hospital Medicine Educational Excellence Award jointly from the Academic Pediatric Association, the American Academy of Pediatrics, and the Society for Hospital Medicine in recognition of her outstanding contributions to advancing educational scholarship and accelerating the development of Pediatric Hospital Medicine Fellowship Programs nationally. Dr. Jerardi received an appointment as associate editor for the Journal of Hospital Medicine, the official journal of the >17,000 member Society of Hospital Medicine.
Matt Kelleher, MD, MEd, received a Golden Apple Teaching Award from the University of Cincinnati medical student classes. This award recognizes excellence in education, small group, and bedside learning experience facilitation, and extraordinary and sustained dedication and effort on behalf of medical student education.
Mia Mallory, MD, MEd, received the Cincinnati Children's Senior Advocacy Achievement Award for leadership of, and successes in, developing a pipeline of diverse physicians within the University of Cincinnati College of Medicine and within the Cincinnati Children's Pediatrics Residency Program.
Katie Meier, MD, became an editorial board member of Pediatrics in Review, an official journal of the American Academy of Pediatrics.
Jennifer O’Toole, MD, MEd, elected as a senior fellow of hospital medicine through the Society of Hospital Medicine. She additionally received the Super Christus Omnia Distinguished Alumna Award, Buffalo Academy of the Sacred Heart, Buffalo, NY.
Michelle Parker, MD, received the Division of Hospital Medicine Clinical Care Award for her exceptional, patient- and family-centered care. Dr. Parker received a selection as an editorial advisory board member of Infectious Diseases in Children, a widely-read national newsletter for pediatricians.
Dr. Schondelmeyer received recognition as a finalist for the Society for Pediatric Research Physician Scientist Award: Bridging to Success. Dr. Schondelmeyer became an editorial board member of Hospital Pediatrics, an official journal of the American Academy of Pediatrics.
Anita Shah, DO, MMR, MPH, received the PEDSnet K12 Award through AHRQ. This grant funds research to develop strategies to address the consequences of adverse childhood experiences. She was also a guest of honor at the National Philanthropy Day for the Association of Fundraising Professionals (AFP). As an invited physician expert, Dr. Shah discussed the impact of Adverse Childhood Experiences (ACEs) and resilience on a panel for the National Philanthropy day hosted by the Greater Cincinnati Chapter of AFP. AFP is an international association with a membership of more than 30,000 fundraisers and 233 chapters throughout the world. The goal of AFP is to advance philanthropy across the globe through advocacy, research, education, certification, mentoring, and networking.
Dr. Shah’s published manuscript titled, “Lost Earnings and Nonmedical Expenses of Pediatric Hospitalizations” in the Journal Pediatrics, received an award as one of the top 10 articles by the Society of Hospital Medicine in 2018. Co-authors on this work included Drs. Beck, Auger, S. Shah and Jeffrey Simmons, MD, MSc. This work quantified the substantial non-medical costs and loss of income that families incur with the hospitalization of their child. It also demonstrated that non-medical costs disproportionately affected those with competing socioeconomic challenges.
Dr. S. Shah received the title of master of hospital medicine by the Society of Hospital Medicine. This award recognizes Dr. Shah’s seminal contributions to the development of the field of Hospital Medicine as an academic discipline. Dr. Shah is only the fourth pediatrician to receive this award in the society’s history. Dr. Shah became editor-in-chief of the Journal of Hospital Medicine, the official journal of the Society of Hospital Medicine. The Society of Hospital Medicine has >17,000 adult and pediatric hospitalist members.
Dr. Thomson became vice-chair of the research subcommittee, Council of Pediatric Hospital Medicine Fellowship Directors.
Ndidi Unaka, MD, MEd, became a named national correspondent for the Journal of Hospital Medicine. In this role, she will partner with adult and pediatric hospitalists nationally to develop a series of clinical problem-solving manuscripts designed to enhance physician clinical decision-making skills.
